Fearmongering about painkillers – codeine

So I’ll preface this post with the following – I am not someone who uses codeine frequently. I don’t suffer from any form of chronic pain, and apart from when recovering from surgery, will probably have medication containing codeine about once every 4 – 6 months.

I am passionate about people being able to access the medication they need, when they need it, without unnecessary hurdles being put in their way, and today’s news about codeine moving to only be available in Australia by prescription, is a hurdle in everyone’s way. From me and my very occasional use, to those who have chronic pain who use it much more frequently.

Also, all the reporting on the topic is frequently terrible, conflating all opioid related deaths with those caused by codeine, and attributing carrier drug deaths and injuries (usually paracetamol or ibuprofin) with codeine.

Let’s start with some important numbers:

Population of Australia (end June 2016) a bit over 24,000,000 (source)

The importance of all these numbers will make sense further down this post.

I’ll start with the ABC article (the second that I read on this today) which claims in part:

“Medication that are available over the counter or through pharmacies should be substantially safe and not subject to abuse.”

Now paracetamol and ibuprofen are safe, generally in the quantities that the box tells you to take them. Excessive paracetamol (overdosing) causes:

Signs of paracetamol overdose include drowsiness, coma, seizures, abdominal pain, nausea and vomiting. Another name for paracetamol is acetaminophen (often known by its brand name, Panadol®).

There is only a small difference between the maximum daily dose of paracetamol and an overdose, which can cause liver damage. Large amounts of paracetamol are very dangerous, but the effects often don’t show until about two to three days after taking the tablets. (source)

Both of these drugs, which are commonly available in Australia, you can buy them almost everywhere (convenience stores, supermarkets, chemists, petrol stations, etc) are only just safe in the recommended doses. If you have a compromised liver, or mix up your dosage, you can cause serious damage to yourself, if not die from the medication.

Neither paracetamol or ibuprofen are addictive however, so apparently it doesn’t matter how dangerous they are.

So the TGA is partly lying. The liver damage and stomach ulceration are the result of the carrier drug, either paracetamol or ibuprofen. I’m not sure how many tablets you’d have to take to get the overdosing effective of codeine from the blended paracetamol/ibuprofen and codeine tablets, but I’m pretty sure that the internal bleeding and liver failure will probably kill you before the “respiratory depression” does.

Dr Greenaway said an Australian study using coronial data showed there had been over 1,400 deaths in a little over a decade.

A little over a decade. Let’s say that’s 13 years since no one has bothered giving us the actual numbers. That’s around 108 deaths per year attributed, apparently, to codeine. Because the ABC (and all the other media outlets) didn’t bother to find the actual source of these figures, I’ve just spent 2 minutes finding them for you.

The rate of codeine-related deaths in Australia more than doubled between 2000 and 2009, driven primarily by an increase in accidental overdoses, according to new research by the National Drug and Alcohol Research Centre at UNSW.

…

“While we can’t look at trends over time beyond 2009, our sample of 1,437 codeine-related deaths between 2000 and 2013 allows valuable insights into the circumstances surrounding these deaths,” said Ms Roxburgh.

Of the 1437 deaths included in the study, just under half (48.8%) were attributed to accidental overdose, and a third (34.7%) to intentional self-harm.

Most codeine-related deaths (1201 = 83.7%) during 2000–2013 were attributed to multiple drug toxicity. A small proportion (113 = 7.8%) were specifically attributed to codeine toxicity. The remaining 123 deaths (8.5%) were attributed to other underlying causes, such as coronary heart disease, cardiovascular conditions, or other drug toxicity.

More than half (53.6%) of the cases of codeine-related death included a history of mental health problems, 36.1% a history of substance use problems (including misuse and dependence), 35.8% a history of chronic pain, 16.3% a history of injecting drug use, and 2.7% a history of cancer.

Those who had intentionally overdosed were more likely to be older, female and have a history of mental health problems; those who had accidentally overdosed were more likely to have a history of substance use problems, chronic pain and injecting drug use.

Ms Roxburgh said these characteristics highlight a complex patient population in need of specialist services.

Ok, so the TGA is being even more dishonest. 123 deaths over a 13 year period were related specifically to codeine toxicity. That’s 9.4 deaths per year. The 1201 deaths were multiple drug toxicity, which would most likely mean, since it isn’t spelt out, that the individuals died from consuming multiple substances, such as paracetamol and/or ibuprofen containing codeine, and potentially other medication. As I’ve already noted, overdosing on paracetamol and ibuprofen is very bad for you.

34.7% of those deaths were suicide. That’s not people getting addicted to codeine and then dying, that’s people using a commonly available drug and committing suicide. I’m sure that those who were intentionally self harming with drugs containing codeine would find any other drug that would have the same outcome, and yet I don’t hear the TGA calling for prescriptions only for ibuprofen and paracetamol.

I included the last bit of the press release because it’s a point I want to come back to. Mostly that addiction is treated like a moral failing and not a social failing.

The use of common, opioid-based painkillers such as codeine, morphine and oxycodone has increased by four times over the past decade and Australian is among a handful of countries consuming the bulk of the world’s opioid medication supply, according to figures from the independent body responsible for implementing the United Nations international drug control conventions, the International Narcotics Control Board, published in the Lancet.

This is deliberately misleading. You cannot get morphine or oxycodone over the counter at a pharmacy. Including these two opioids in a discussion about codeine is muddying the waters. Also, Australia “is among a handful of countries”. What does that even mean? What is a handful of countries, who are the other countries, and given we produce a lot of our own opioids, what relevance does this have?

The Australian Medical Association has said it accepts the plan will result in additional health system costs and higher workloads for GPs, but AMA vice-president Stephen Parnis said that should be weighed up against the cost of harm inflicted by the misuse of codeine, intentional or otherwise.

The TGA is making a currently available, over the counter, widely used and not widely abused drug, into a prescription only drug in an environment where the current Australian government is attempting to reduce the number of subsidised doctor’s visits to everyone (source), which will make life even more difficult for those with chronic pain conditions.

“We also know that the number of people suffering avoidable harm in this area has been increasing over time, to the point where, at least in Victoria, the number of deaths from overdose of prescription narcotics is higher than the road toll.”

And my numbers come into play. The road toll for Victoria in 2015 was 257. The number of people who die (on average according to the National Drug and Alcohol Research Centre) is about 110 per year.

Ah… but see what AMA actually said, “the number of deaths from overdose of prescription narcotics”. This decision is about over the counter codeine. It is not about prescription opioids of any other kind, and yet in attempting to justify a decision which is really just going to annoy and make life harder for people, we get all these other reasons.

“The body converts it to morphine and in fact a proportion of the population can convert it so quickly that they can suffer serious harm as a result.”

This is true, but moving to a prescription based service is not necessarily going to root this out. Are doctors going to get more training and time to treat addiction? Are doctors going to know which person amongst the hundreds of their patients has a metabolism that can quickly convert codeine to morphine and potentially harm themselves as a result? It’s very unlikely.

A TGA statement released on Tuesday morning said there was evidence that misuse of codeine contributes to liver damage; stomach ulceration and perforations; low blood potassium levels; respiratory depression and death.

The TGA’s statement, again, is incorrect. Misuse of paracetamol and ibuprofen contributes to liver damage, stomach ulceration and perforations, and low blood potassium levels. The TGA is conflating two different sets of harm caused by different drugs, into one in order to bolster their position.

The decision comes after reports of codeine addicts swallowing up to 100 tablets a day, and people “pharmacist shopping” to get around rules introduced in 2010 that restrict purchases of more than five days’ supply of the drug at one time.

“reports of codeine addicts”, citation needed. Also, any more than 6 (ibuprofen) or 8 (paracetamol) tablets, yet alone 100 tablets a day is an overdose amount of paracetamol or ibuprofen. I call bullshit on this claim.

Also, it’s not hard to “pharmacy shop”, almost everyone has to do it at one point. Some pharmacists treat anyone who asks for certain types of medication as drug-seeking,, whether it be something containing codeine or pseudoephedrine (the one that works versus phenylephrine which doesn’t), or something else. If a pharmacist treats you badly, you go to another pharmacy (if you can).

Despite the fact that pseudoephedrine can be used to make cheap, bathtub, biker speed (Tripod quote), you don’t have to get a prescription to get it. Sales of products containing pseudoephedrine plummeted when manufacturers substituted in an ineffective ingredient (claiming it was helpful even though studies said it wasn’t), and pharmacists started treating customers who – legally – sought to buy the stuff that does work as though they were drug-seeking addicts. The same could be done to codeine really.

In 2013, Monash University researchers reported nine deaths over a decade linked to toxicity from codeine-ibuprofen medicines such as Nurofen Plus.

Less than one death a year from codeine and ibuprofen. More women are killed in intimate partner violence per year and sadly the Government is doing sweet fuck all about that. More people die on our roads each year, and the Government does quite a bit about that. Also I don’t know whose figures to believe. I’m not sure if this 9 deaths are just in Victoria, or are from a different type of study as undertaken by National Drug and Alcohol Research Centre.

Government agency data also shows the number of Australians being treated for codeine addiction more than tripled over the decade to 2012-13, from 318 to more than 1000 a year.

More than 1000 a year. That’s 0.0004% of Australia’s population. Apparently that number (the 1000) is probably under reported as some people treat themselves for codeine addiction. There isn’t any discussion as to how much codeine addiction costs the health system, so it’s hard to know if more than 1000 people being addicted to codeine, who want to not be addicted any longer, is a huge cost to the medical system or just an inconvenience.

This is in error. Loads of resources and articles say that emergency hospitalisation of someone overdosing on codeine compounds cost about $10,000 each. The AMA says “A review of 99 hospitalisations caused by the misuse of OTC analgesics containing codeine found they cost, on average, $10,000 per admission.” That’s broken down a bit more over here where we find out that most of it is once again ibuprofen’s fault.

28 tablets per day? That’s a lot.

When you treat addiction as a moral failing, despite the fact that most of the people who use codeine regularly are people who have chronic pain conditions, then you let everyone down. The next person who becomes addicted to codeine after surgery or a bad fall is listed as the failure, instead of just something that sometimes happens when you’ve sustained certain injuries, have certain medical conditions, or have gone through major surgery.

Those who had intentionally overdosed were more likely to be older, female and have a history of mental health problems; those who had accidentally overdosed were more likely to have a history of substance use problems, chronic pain and injecting drug use.

Ms Roxburgh said these characteristics highlight a complex patient population in need of specialist services.

Instead of treating the underlying conditions that people, who use codeine regularly, have, we treat them like they are the problem. Instead of treating addiction as an illness, we treat it as a moral failing. We fail everyone when we act this way, and the TGA needs to actually consider the messages they’re giving those who use codeine regularly, and to stop misleading the public about the actual harm of codeine.